Eyeworld

EW NEWS & OPINION 18 March 2015 Anterior segment grand rounds (ASGR) A 78-year-old woman was referred to my practice for recurrent microhy- phema occurring upon awakening in the right eye. She started waking up in the morning about 3 years ago with occasional blurred vision OD that would clear as the day progressed, but the problem has become more persistent and now occurs almost every day. She had cataract surgery in the right eye 10 years ago with an AcrySof 1-piece IOL (Alcon, Fort Worth, Texas) placed within the capsular bag and had no problem for the first 7 years after surgery. The first time I saw her she came in early in the morning with a significant amount of blood in the anterior chamber so it was difficult to see any details. Her vision was 20/100, and IOP was 35 on topical Combigan (brimonidine tartrate/timolol maleate, Allergan, Irvine, Calif.) and Travatan (travoprost, Alcon). You can see what her eye looked like in Figure 1. Because the details of slit lamp exam- ination were obscured by the blood, I asked her to go for breakfast and come back in a few hours, hoping the blood would settle out a bit and I would have a better view of anterior chamber details. When she returned, things had cleared up significantly and upon dilating her I was able to ascertain that the implant, a 1-piece AcrySof IOL, was entirely within the capsular bag, and covered by anterior capsule 360 degrees. See Figures 2 and 3. They demon- strate that the lens is clearly in the capsular bag with 360-degree optic overlap of the anterior capsule. I noticed that the capsular bag was amazingly transparent and clear, and it looked as if the surgery was done just a week or so ago rather than 10 years ago. The bag was quite thin and diaphanous appearing with no fibrosis whatsoever. I also noted that there was a very fine "shimmer- ing" iridodonesis. I decided to bring her back another day to examine her when she wasn't dilated. See Figure 4. I could see what appear to be iris transillumination defects overlying where the haptics reside nasally and temporally within the capsular bag. While these were somewhat faint at 8 to 9 o'clock, they were seen quite easily at 2 to 3 o'clock. I con- sulted some esteemed colleagues for their thoughts on what is going on here and what they would do about it. Steven G. Safran, MD, ASGR editor by Steven G. Safran, MD capsulorhexis. If the IOL is totally in the sulcus then an IOL exchange would be performed and a 3-piece IOL would be placed in the ciliary sulcus again with a possible anterior vitrectomy. If the zonules appeared weak or there was pseudoexfolia- tion, then a scleral fixation of the current IOL could be performed. For scleral fixation I would use 9-0 pro- lene sutures placed 180 degrees apart at the haptic/optic junction. The sutures would be placed in the sclera 2.0 mm posterior to the limbus and oriented radially to the limbus." Mike Snyder, MD, said: "This patient definitely has UGH syn- drome. The transillumination in the last figure appears to correlate with the location of the nasal haptic end, based on the gonioscopy. The transillumination is more peripheral than one would expect from a hap- tic contained within the confines of J ohn Hart, MD, comment- ed: "The morning microhy- phemas could correspond to weak zonules allowing the capsular bag/IOL complex to move anteriorly, causing chafing of the posterior iris over the IOL haptic. The anterior capsule is described as being non-fibrotic and thin, appearing like the surgery was done last week and not 10 years ago. Occasionally, if a single-piece IOL is completely in the ciliary sulcus, the anterior capsule will appear clear when viewed through the IOL optic. Then again, sometimes the anterior capsule is just thin and non-fibrotic even 10 years after surgery. "In summary, the patient presents with a 3-year history of uveitis-glaucoma-hyphema (UGH) syndrome with a single-piece acrylic IOL that is apparently in the capsu- lar bag. Transillumination defects in the base of the nasal iris in the area of one of the haptics is likely the site of the problem. So how do we treat this patient? "Because her IOL is not dislocat- ed and no pseudophacodonesis is re- ported, medical management could be initiated to attempt to stop the recurrent microhyphemas. I would add atropine 1% one drop BID and recheck her in 2 weeks. If her IOP improved, and the microhyphemas ceased with atropine and she was tolerant of mydriasis, this may be the only intervention necessary, and I would have her use the atropine long term. If her symptoms con- tinued or if she were intolerant of atropine, then surgical management would be indicated. "The patient would be in- formed that a surgical exploration would better define what needs to be performed. The patient would be consented for surgical explora- tion with possible IOL exchange or scleral fixation of the current IOL and possible anterior vitrectomy. At surgery, the iris would be retracted with a Kuglen hook under a disper- sive OVD to expose the zonules and the area with the iris transillumina- tion defect. If the zonules appeared to be in good shape with no pseu- dophacodonesis and no PXF, the sin- gle-piece IOL would be exchanged for a 3-piece IOL with the haptics either in the bag or in the sulcus, but if placed in the sulcus then the optic would be captured within the Groundhog Day microhyphema continued on page 20 the capsular bag. While it would be an interesting speculation that the capsule is so thin as to permit the sharp-edged haptic to cause chafe, even when wrapped by capsule, I think it is more likely that there is an occult break in the equator of the bag through which the haptic may have migrated. While the optic is fully covered by the capsulorhexis, that does not guarantee that the peripheral bag is intact. "Notwithstanding, therapeu- tically I would consider trying to viscodissect the capsular bag open and exchanging the current IOL for a 3-piece PCIOL with a rounded an- terior edge, placed in the ciliary sul- cus with the optic captured into the capsular bag. This will ensure long- term centration, as a 3-piece IOL in the bag could migrate into the same point of weakness and decenter. Figure 1: Right eye on presentation with active hyphema Figure 2: Slit lamp image showing IOL completely within capsular bag and covered by anterior capsule

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